A billing morass


I HAVE no idea whether Congress and the health care industry are capable of designing a national system of health insurance that is both compassionate and workable.

But until the people running the present system come up with a billing and reimbursement system that makes sense, count me among the non-believers.

As anyone who has ever gotten sick knows, medical bills are written in secret code, and insurance company payments are calculated by somebody someFrank D.Roylancewhere who yawns and spins a Wheel of Fortune.

And if you have the moxie to question a billing statement, you are answered by a computer programmer who writes back: "PB PB AB OBL IP. 6278 INJG."

The only thing that is loud and clear on a medical bill is the line which says: "PAY THIS AMOUNT."

Let me relate just a few tales from The Dark Side of my wife's recent out-patient surgery. (It went beautifully, thank you. There is no complaint here about the quality of care she received.)

A month after she came home, the bills and insurance statements started finding us, first in a drizzle, then a steady torrent.

FROM THE SURGEON: "Patient balance due: $5,186. Thank you for prompt payment of your bill," it says. Most of it is already marked overdue.

But do I really owe all this? Unless you're uninsured, it seems you hardly ever really owe what the bills say you owe. The numbers are always changing.

I have a good insurance plan. Surely the insurance company hasn't finished paying on this bill. But the statement shows the insurance company has already paid, or disallowed, $1,300. Will it pay more? When? How can we tell? How do we face the surgeon until then?

I send the doctor $100 and express my confusion. I get back a two-page printout labeled "Patient Account Inquiry." It says things like: "Procedure: 9; Diagnosis: 9; Ins.: P; A:N.; Reference #04664755."

Maybe I'll wait for the collection agency to call. They always make things clear.

FROM THE SURGICAL ASSISTANT: A handwritten bill for $1,500. Who is this person? And how did he earn $1,500? The insurance company, too, is skeptical. It rejects $1,250 of the fee, pays $200 and leaves me with $50 to pay. I pay it, but a month later I get another insurance statement marked with a code "A" suggesting the guy is trying again for more money. For now, it says, "No action on your part is necessary." But how much will I owe when he's through?

FROM THE "PHYSICIANS SERVICES CORP.": A bill for $78 for "professional interpretation" of a pathology test. I owe $12.82 after insurance. I don't know precisely what this corporation did, but it sounds important. And if I can settle it for $12.82, I'll pay it.

FROM THE HOSPITAL: $2,127 billed and fully paid by insurance. Thank you. This is how all these transactions should go.

FROM THE ANESTHESIOLOGIST: A bill for $768. The insurance company throws out $208 of the fee, but pays $448, noting that I am responsible for the rest -- $112. I believe and pay.

A week later I get a check for $112 from the anesthesiologist, which I cash immediately. He also encloses a printout that, as far as I can tell, shows he received three checks from the insurance company totaling $896, or $128 more than he charged for his services.

Go figure.

Frank D. Roylance is an Evening Sun reporter.

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